Provider Demographics
NPI:1780728774
Name:BARR, SUSAN (OT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BARR
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4712
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-674-6155
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-674-6155
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1308225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888410200Medicaid